1. Hospice Wage Index And Payment Rate Update Hospice Quality Reporting Requirements Updates On Payment Reform Components Of FY2014 Proposed Hospice Wage Index Rule – Posted April 29, 2013

2. FY2014 Hospice Wage Index Proposed Rule 2 Proposed FY2014 Hospice Payment Update Percentage Hospital Marketbasket 2.5%  Productivity adjustment reduction -0.4%  Hospice-specific marketbasket reduction -0.3% FY2014 Hospice Payment Update %1.8%  Updated wage index - 0.7% Estimated Final FY2014 Hospice Payment Update % 1.1%

3. Wage Index Tables  FY2014 wage index tables  http://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/Hospice/index.html http://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/Hospice/index.html  NHPCO will issue wage index calculator and state- by-state charts in coming days  Watch NHPCO website at www.nhpco.org/regulatory www.nhpco.org/regulatory

4. Rate Comparisons 4 Level of CareFY2013 National Rate FY2014 National Rate FY2014 National Rate with Sequestration Routine Home Care $153.45$156.21$153.08 Continuous Home Care $895.56$911.68$893.45 Inpatient Respite $158.72$161.58$158.35 General Inpatient Care $682.59$694.88$680.98

5. Big Changes Coming 5  Coding requirements – NO debility or adult failure to thrive  Implementation of HIS – Hospice Item Set for all patients  Implementation of Hospice Experience of Care survey (Hospice CAHPS)  Payment Reform  Cost report changes

6. Questions and Comments

7. Debility, Adult Failure to Thrive Alzheimer’s and Other Dementias Using ICD-9-CM Coding Conventions Multiple Diagnoses on Claim Form 7

8. Clarifications on Coding Requirements 8  “All of a patient’s coexisting or additional diagnoses” related to the terminal illness or related conditions should be reported on the hospice claims  72% of hospice claims report only one diagnosis  CMS conclusions.....

9. Debility and Adult Failure to Thrive 9  Diagnoses found in “Symptoms, Signs, and Ill- Defined Conditions” section of ICD-9-CM  “Debility” and “adult failure to thrive” SHOULD NOT be used as principal hospice diagnoses on the hospice claim form  Reference – ICD-9-CM Coding Manual  Choose the diagnosis “most contributory” to the terminal illness  Claims with this diagnosis will not be paid and will be returned to provider (RTP)

10. Alzheimer’s and Other Dementias 10  Diagnoses in coding classification “Mental, Behavioral, and Neurodevelopmental Disorders”  Not allowable as a principal diagnosis per ICD-9-CM coding guidelines  Diagnoses in ICD-9-CM coding classification “Diseases of the Nervous System and Sense Organs”  Can be used as principal diagnoses per ICD-9-CM coding guidelines

11. Final Message on Coding Conventions 11  Imperative that hospice providers follow ICD-9-CM coding guidelines and sequencing rules for all diagnoses  Pay particular attention to dementia coding  Dementia codes found in more than one ICD-9-CM coding chapter  Code the most definitive, contributory terminal illness in the principal diagnosis field  with all other related conditions in the additional diagnoses fields for hospice claims reporting

12. Questions and Comments

13. Quality Reporting 13

14. Quality Reporting 14  2013/2014 Data Collection and Submission  QAPI structural measure  NQF #0209 – pain measures  CMS proposes that these measures discontinued after FY2014 data collection year OR  CMS proposes to continue using #0209 until another pain outcome measure is available

15. New Quality Reporting 15  Hospice Item Set (HIS)  Proposed to implement July 1, 2014  Data on admission and discharge of every patient  Data collection to include information for 7 new quality measures  Hospices who fail to report quality data via the HIS system in 2014 will have a 2% marketbasket reduction for FY2016  Public reporting on hospice quality measures  Not initiated prior to 2017

16. Seven New Quality Measures 16 NQF Measure #Hospice Quality Measure Description NQF #1617Patients Treated with an Opioid who are Given a Bowel Regimen NQF #1634Pain Screening NQF #1637Pain Assessment NQF #1638Dyspnea Treatment NQF #1639Dyspnea Screening NQF #1641Treatment Preferences NQF #1647Beliefs/Values Addressed (if desired by the patient)

17. HIS Forms Now Available 17  http://www.cms.gov/Regulations-and- Guidance/Legislation/PaperworkReductionActof19 95/PRA-Listing- Items/CMS1252151.html?DLPage=1&DLSort=1&D LSortDir=descending http://www.cms.gov/Regulations-and- Guidance/Legislation/PaperworkReductionActof19 95/PRA-Listing- Items/CMS1252151.html?DLPage=1&DLSort=1&D LSortDir=descending

18. HIS Publishes HIS Forms 18  One form for each admission  Administrative information  Measure support information Preferences NQF #1641 – Treatment preferences NQF #1647 – Beliefs/Values Addressed (if desired by the patient) Health conditions NQF #1634 Pain Screening NQF #1637 Pain Assessment NQF #1638 Dyspnea Treatment NQF #1639 Dyspnea Screening Medications NQF #1617 - Patients treated with an opioid who are given a bowel regimen

19. HIS Publishes HIS Forms 19  One form for each discharge  Demographic data  Reason for discharge

20. New Quality Reporting 20  Hospice Experience of Care Survey  Post-death caregiver survey  Hospices required to contract with a vendor for survey administration and quarterly data submission  Proposed start date: CY2015  First quarter – “dry run” for at least 1 month  Mandatory compliance – April 1, 2015  Fewer than 50 deaths in year: exempt

21. CMS Website Location 21  http://www.cms.gov/Regulations-and- Guidance/Legislation/PaperworkReductionActof19 95/PRA-Listing-Items/CMS- 10475.html?DLPage=1&DLFilter=hospice&DLSort= 1&DLSortDir=descending http://www.cms.gov/Regulations-and- Guidance/Legislation/PaperworkReductionActof19 95/PRA-Listing-Items/CMS- 10475.html?DLPage=1&DLFilter=hospice&DLSort= 1&DLSortDir=descending

22. Three Experience of Care Surveys 22  Home  Nursing Home  Inpatient o Set of core questions with additional setting specific questions o Location at death determines which version is used

23. Reconsideration process for hospice quality reporting  A process will be created to allow hospices that have been notified of non-compliance with hospice quality reporting requirements  May request reconsideration of FY 2014 payment determinations

24. Questions and Comments

25. Hospice Payment Reform

26. Payment Reform Options  U-shaped model of resource use  Considering a tiered approach with payment tiers based on length of stay  Short-stay add-on payment  Case-mix adjustment  Rebase ( ) the routine home care rate  Site of service adjustment for hospice patients in nursing facilities

27. U-shaped Model 27  Higher payments at the beginning of care  Higher payments in the last days of life  Lower payments in the “middle” of care  No determination on number of days or payment level

28. Short stay add-on 28  Could improve payment accuracy  Somewhat like home health Low Utilization Payment Amount (LUPA)

29. Case mix adjustment 29  Could be considered when more diagnosis data is available  Contingent on data gathering from multiple diagnoses on claim form

30. Rebase the Routine Home Care Rate Note: No action proposed on this issue this year. Routine Home Care Components 1983 Cost per Day Inflation Factor FY2011 Cost per Day Example of rates for FY2014 Proposed FY2014 Rates Nursing Care$16.25N/A$56.54$60.83 Home Health Aide$12.74N/A$19.24$20.70 Social Services/Therapy $3.23N/A$10.29$11.07 Home respite$1.46X 3.1704$4.63$4.98 Interdisciplinary group $2.78X 3.1704$8.81$9.48 Drugs$2.78X 3.1704$3.74$4.02 Supplies$4.49X 3.1704$14.23$15.31 Equipment$1.13X 3.1704$3.58$3.85 Outpatient Hospital Therapies $2.99X 3.1704$9.48$10.20 TOTAL$46.25$130.54$140.44$156.21

31. CMS Commentary on Rebasing 31  Do not have the data to support rebasing six of the nine cost components described in the 1983 final rule  Drugs, supplies, and equipment costs -- not available from hospice claims data  Cost report data not sufficiently detailed  Could consider rebasing:  Nursing  Home health aide  Social services/therapy  Comprise 69.7% of RHC rate  Use FY2011 cost report data matched to FY2011 claims data

32. Site of service rate adjustment for nursing home patients on hospice  Issues  Growth OIG Report in 2011 – 263 hospices have 66% or more patients in nursing homes  Possible efficiencies – multiple patients in one nursing home, < drive time and < mileage  Higher aide visits and time for hospice patients in nursing homes  NO action proposed on this issue this year

33. Additional Data Collection  January 2013, CMS received comments regarding additional data collection  Considering input  Additional data to be issued as a change request (CR) this spring or summer

34. Interested Policymakers  MedPAC – U-shaped curve and modeling  June 2013 Report to Congress  CMS  Abt Associates and Technical Expert Panel  Extensive analysis of claims and cost report data  HHS Assistant Secretary for Planning and Evaluation  ASPE  Extensive data analysis – especially visits and visit length

35. V ALUE B ASED P URCHASING 35  Value based purchasing – pilot testing  Utilize already implemented measures  Implement pilot by January 1, 2016

36. Questions and Comments

37. Want to send comments?  Go to www.regulations.govwww.regulations.gov  In the search box, type hospice  The proposed rule, CMS-1449-P, will come up. Click the blue “Comment Now” box to submit your comments.  An official letter from your hospice may be attached.

38. Address  Address the letter as follows: Marilyn Tavenner, Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS–1449–P P.O. Box 8010 Baltimore, MD 21244–8010  Comments are due June 28, 2013

39. Thank you for your time and input!